Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Monday, July 23, 2007

Back to the Knitting

Okay, enough for a while of vile, degrading politics. I've been working with colleagues to analyze audiotapes of medical visits, adults seeing, for the most part, doctors with whom they have a long standing relationship.

These conversations are astonishingly asymetrical. You'd be surprised how little of the typical visit consists of discussion of the patient's health, symptoms, treatments, etc., in many cases. A lot of time is taken up discussing logistics (referrals, obtaining records, getting prescriptions refilled, etc.) and often a lot is spent on idle chit chat. But when discussing the patients' health -- symptoms, diagnostic test results, diagnosis and treatment -- doctors ask 86% of the questions. They also control the agenda, making nearly 80% of the utterances that open or close topics.

It might surprise you that in discussion of psychosocial issues -- things like patients' housing situation, substance abuse, criminal justice involvement, employment, family situation -- the asymmetry is even more extreme. Here, doctors ask 90% of the questions and give only 14% of the information. (In some other areas, such as prescribing antiretroviral medications -- these patients all have HIV -- the patterns are somewhat different.)

So let's think about this. Of course doctors have to ask questions and get information from us in order to figure out what's wrong with us and offer appropriate treatment. But shouldn't we be asking almost as many questions, and getting almost as much information from them? Shouldn't we be benefitting from the physician's expertise, not just so they can do things to us or tell us what to do, but so that we can understand what they believe is happening to us, what will likely happen in the future, and the factors underlying medical decision making such as risks and benefits of treatment, alternatives, and even doing nothing? That way, we can participate in decision making and choose the course that's best for us, given our risk aversion, pain tolerance, preferences, and the lives we need to lead.

If they're working for us, we ought to be telling them what to do some of the time, but physicians give almost 90% of the directives (recommendations, requests and orders). One of our readers, in fact, recently e-mailed me because she wasn't happy with a treatment her doctor wanted to prescribe. She had, it seemed to me, perfectly legitimate reasons for wanting to do something else, but most of us just can't have that conversation with our doctors. Sometimes they really don't like it -- they're the expert, and they don't want to put up with questions and doubts. Sometimes, we're just afraid that's how they'll react, because we're accustomed to doctors behaving that way.

But research has shown that patients who ask more questions and tell the doctor what to do some of the time actually have better outcomes -- specifically, in one well-known study, better control of their blood sugar if they have diabetes. In other words, forming a partnership with your doctor in which you are able to talk with each other as equals can actually make you healthier. I don't know if many doctors are ready for this, but I hope you'll try it. Let me know how it goes.